Clinical Study Efficacy of Physiotherapy for Urinary ...downloads.hindawi.com/journals/bmri/2014/785263.pdf · Clinical Study Efficacy of Physiotherapy for Urinary Incontinence following

Clinical StudyEfficacy of Physiotherapy for Urinary Incontinence followingProstate Cancer Surgery

Elhbieta Rajkowska-Labon,1 StanisBaw BakuBa,1

Marek Kucharzewski,2 and Zbigniew UliwiNski3

1 University and Hospital Department of Rehabilitation, Institute of Physiotherapy at Gdansk Medical University, Poland2Department of Descriptive and Topographic Anatomy, Medical University of Silesia, Ul. Jordana 19, 41-808 Zabrze, Poland3Head of Institute of Physiotherapy, Faculty of Health Sciences, Jan Kochanowski University at Kielce, Poland

Correspondence should be addressed to Elzbieta Rajkowska-Labon; [email protected]

Received 15 January 2014; Accepted 4 February 2014; Published 24 April 2014

Academic Editor: Jakub Taradaj

Copyright © 2014 Elzbieta Rajkowska-Labon et al. This is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.

The study enrolled 81 with urinary incontinence following radical prostate-only prostatectomy for prostatic carcinoma.The patientswere divided into two groups. The patients in Group I were additionally subdivided into two subgroups with respect to thephysiotherapeuticmethodused.Thepatients of subgroup IA received a rehabilitation programconsisting of three parts.Thepatientsof subgroup IB rehabilitation program consist of two parts. Group II, a control group, had reported for therapy for persistenturinary incontinence following radical prostatectomy but had not entered therapy for personal reasons. For estimating the levelof incontinence, a 1-hour and 24-hour urinary pad tests, the miction diary, and incontinence questionnaire were used, and forrecording the measurements of pelvic floor muscles tension, the sEMG (surface electromyography) was applied. The therapyduration depended on the level of incontinence and it continued for not longer than 12 months. Superior continence outcomeswere obtained in Group I versus Group II and the difference was statistically significant. The odds ratio for regaining continencewas greater in the rehabilitatedGroup I and smaller in the group II without the rehabilitation. A comparison of continence outcomesrevealed a statistically significant difference between Subgroups IA versus IB.The physiotherapeutic procedures applied on patientswith urine incontinence after prostatectomy, for most of them, proved to be an effective way of acting, which is supported by theobtained results.

1. Introduction

The International Continence Society defines urinary incon-tinence as involuntary leakage of urine that has been diag-nosed objectively and is associated with additional hygienicand social problems [1]. The most common types of urinaryincontinence following radical prostatectomy include stressincontinence, urge incontinence, and mixed incontinence.The European Association of Urology recommends twoapproaches to the management of these dysfunctions: non-invasive and invasive (surgical) [2]. Noninvasive modali-ties are considered first-line treatment during the first 6–12 months following prostatectomy [3]. Physiotherapy isadministered especially early on after the onset of symptomsand in incontinence of moderate severity. At the same time,

the approach to men with urinary incontinence followingprostatectomy is not unified. An optimal rehabilitation planrequires prior determination of the type of urinary incon-tinence and of factors that may influence volitional con-trol of micturition (motor control, musculo-fascio-skeletalrelations, and behavioral factors) [4]. The choice of invasiveversus noninvasive treatment depends on the severity andduration of symptoms and the type of urinary incontinence.Conservative modalities include physiotherapy techniques,the most common of which, used in male incontinencefollowing prostatectomy, include pelvic floor muscle training(PFMT) with or without biofeedback (BFB), noninvasivepelvic floor electrical stimulation, extracorporeal magneticinnervation (ExMI), behavioral modification, and externalpenile compression devices [5–8]. A standardized program

Hindawi Publishing CorporationBioMed Research InternationalVolume 2014, Article ID 785263, 9 pageshttp://dx.doi.org/10.1155/2014/785263

2 BioMed Research International

of pelvic floor muscle reeducation that would guaranteecomplete therapeutic success is yet to be developed. However,it is quite clear that a plan of pelvic floor muscle trainingshould determine the level of exercise intensity with regard toexercise duration, the number and frequency of repetitions,and the type of load to induce permanent changes in themuscles [9–11]. Of no less importance for the final outcomeof therapy are the patient’s motivation, the correct executionof exercises, and compliance with the physiotherapist’s orders[12].

The aim of the present study was to evaluate continenceoutcomes in a group of postprostatectomy males who under-went physiotherapy (Group I) as compared to a controlgroup of males not undergoing physiotherapy (Group II)and to compare outcomes between Subgroup IA and IB,treated using different physiotherapy methods. Outcomeswere also evaluated with regard to time between surgery andrehabilitation in SubgroupA (<3months) and B (>3months).The odds ratio for regaining continence in Group I versus(control) Group II was also evaluated.

2. Materials and Methods

The study enrolled 81 males aged 53–82 years (mean age68 ± 6.65 years) with urinary incontinence following radicalprostate-only prostatectomy for prostatic carcinoma.

The exclusion criteria included patients with an artificialpacemaker, musculoskeletal deformities making rehabilita-tion impossible, bleeding from the urinary bladder or thedigestive tract, urinary tract infection, polyuria, uncontrolleddiabetes mellitus, neurologic conditions affecting coordina-tion and balance, lack of consent of the patient to commencetherapy, and previous rehabilitation for urinary incontinence.

The patients were divided into two groups. Group I com-prised 𝑛 = 49 males aged 54–80 years (mean age 67.9 ± 6.81years). The patients in Group I were additionally subdividedinto two subgroups with respect to the physiotherapeuticmethod used.

Subgroup IA (𝑛 = 23) was made up of patients aged 54–77 (mean age 66.9 ± 7.07 years). These patients received arehabilitation program consisting of three parts as follows:

(a) pelvic floormuscle training (PFMT)with biofeedback(PFMT + BFB) (once weekly for 20–30min),

(b) pelvic floor muscle training according to spinal seg-mental stabilization principles (PFMT + SSS) (onceweekly for 30min),

(c) a set of exercises for the patient to perform on his ownat home (3 times daily for 15–20min).

The set of exercises comprised isolated contractions ofPFMT and the urethral sphincter and particular pelvic floormuscle exercises according to the principles of spinal segmen-tal stabilization training, performed in the lying, sitting, andstanding positions.

The efficacy of PFMT with BFB was recorded graphicallyin a chart and numerically (in seconds and microvolts) usingsEMG with a dual channel software-assisted Neuro Trac ETSdevice from Verity Medical Ltd. All patients from Subgroup

IA had an individual anal probe mounted. A self-adherentreference electrode was positioned onto previously defattedakin at an electrically inactive site on the anterior superioriliac spine. The electrodes were FAD- and CE-certified.

Subgroup IB comprised a total of 𝑛 = 26 patients aged 57–80 (mean age 68.8 ± 6.59 years) subjected to a rehabilitationprogram involving the following:

(a) PFMT without BFB according to the principles ofsegmental spinal stabilization training (twice weeklyfor 30min),

(b) A program of home-based exercises identical to thatfor Subgroup IA.

Subgroup IB included those patients who had not agreedto have an anal probe mounted for exercises.

All patients followed a standardized and reproducibleexercise program.

Therapeutic sessions in both subgroups were one-on-onemeetings between patients and one physiotherapist at theDepartment of Rehabilitation, Gdansk Medical University.Patients commuted for the sessions from their place ofresidence. The rehabilitation program was administered topatients who had developed urinary incontinence followinga prostate-only prostatectomy and had been referred forrehabilitation by a urologist. The rehabilitation program inSubgroups IA and IB was divided into a number of stages.

Stage I, the same in both groups, began with educatingthe patient about the anatomy and physiology of the lowerurinary tract and the respiratory system, the physiologyof micturition, and muscle synergies between the muscu-loligamentous system of the pelvic complex and pelvic floormuscles.

In Stage II, also the same in both groups, the therapistcarried out exercises with the patients according to theprinciples of segmental spinal stabilization training. Muscleactivation involved kinesthetic awareness in tensing mus-cles while the patient maintained a neutral position of thespine. The exercises were performed at a slow pace, with aloading threshold of 20–25% of maximum MVC (maximumvoluntary contraction strength), duration of muscle tensingof 5–10 seconds, and 7–10 repetitions. Training progressionconsisted of stimulating muscles of the external group atisolated positions while maintaining control of tensing,changes in starting positions for exercises, exercises in openand closed kinematic chains, sensorimotor exercises onunstable bases (mattress, theraband ball, and disks), and theaddition of resistance and functional exercises. The durationof physiotherapy in both subgroups depended on the severityof incontinence. The therapy ended when continence wasregained but did not last longer than one year.

The third stage was only implemented in Subgroup IAand involved the incorporation of biofeedback tomonitor theparameters of pelvic floor muscle training.

The severity of incontinence was determined with the1-hour and 24-hour pad test, where the number of padsused before and after therapy was recorded by patients inmicturition diaries. Pelvic floor muscle tension was recordedand measured by sEMG (surface electromyography).

BioMed Research International 3

The continence thresholds were 2 g in the 1-hour pad testand 4 g in the 24-hour pad test. Continence parameterswere assessed at the beginning (baseline) and on completionof the therapy. Patients were divided into subgroups withregard to the amount of urine leaked to determine whetherbaseline urine loss would influence continence outcomes ofthe physiotherapy.

Group II, a control group, comprised 32 men aged 53–82 years (mean age 68.3 ± 6.49 years) who had reportedfor therapy for persistent urinary incontinence followingradical prostatectomy but had not entered therapy for per-sonal reasons. 1-hour and 24-hour pad tests were conductedwhen the patients reported for therapy and repeated at oneyear postsurgery. Information on continence outcomes wascollected by phone on the basis of patients’ self-reportedsubjective assessment.

Consent for conducting the study was given by theIndependent Ethical Review Board for Scientific Research atGdansk Medical University (NKEBN 208/2011).

The study data were analyzed in STATISTICA 9.0. TheKolmogorov-Smirnov test was used to determine data distri-bution patterns. Quantitative characteristics were comparedbetween the two populations with the Mann-Whitney𝑈 test.A statistical test for dependent samples was used to compareparameters for the same population (group) before and aftertreatment. The Chi2 test was used to define correlationsbetween two qualitative variables. A test for differencesbetween two components of a structure served to verify thesignificance of particular frequency distributions (of patientnumbers and percentages) of specific variable categories.Regression analysis was used additionally to assess oddsratios. A 𝑃 value of 𝑃 < 0.05 was regarded as statisticallysignificant in all analyses.

3. Results

The 1-hour and 24-hour pad test were conducted in patientsfrom Groups I and II before rehabilitation was started inorder to test for homogeneity of the groups with regard to theamount of urine leaked. The tests did not reveal statisticallysignificant differences between the groups (𝑃 = 0.329 for the1-hour test and 𝑃 = 0.105 for the 24-hour test).

The 1-hour pad test was also used to provide an objectivemeasure of the amount of urine leaked before and afterrehabilitation in Group I patients (𝑛 = 49). The resultsshowed a statistically significant difference (𝑃 < 0.001) inreducing the loss of urine. 24-hour pad test data also showeda statistically significant difference between measurementsbefore versus after rehabilitation therapy (𝑃 < 0.001). Thenumber of pads used per day before and after therapy (185versus 58) was analyzed based on data from micturitiondiaries. A significant reduction in the number of pads usedwas observed following the therapy compared to baselinedata (𝑃 < 0.001). Differences in demand for pads for theentire study group are presented in Figure 1.

sEMG traces obtained during biofeedback exercises forpelvic floor muscles were analysed statistically with regardto the following parameters: arithmetic mean of contraction

Wykres ramka-wasyWarunek uwzgledniania: �12 = 1

Mediana25%–75%

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Figure 1: Differences in the amount of urine leaked before andafter therapy for Group I (𝑛 = 49). Box-and-whiskers diagram.Case selection condition. 24-h test baseline (grams). 24 h testposttreatment (grams). Median. Min-max.

voltages (𝜇V), mean deviation of contraction voltages (%),mean response time (s), arithmetic mean of relaxation volt-ages (𝜇V), mean deviation of relaxation voltages (%), andmean relaxation time (s).These indices weremeasured beforeand after therapy.

The only statistically significant (𝑃 = 0.03) differenceamong these values was in response times before andafter treatment for continent versus incontinent patients.No significant differences were revealed with regard to theremaining indices.

On completion of the therapy, continence (C) had beenrestored in 9/23 (39.1%) patients in Subgroup IA, while14/23 (60.9%) patients remained incontinent (INC) at variousdegrees of severity. In Subgroup IB (𝑛 = 26), continence hadbeen restored in 24/26 (92.3%) patients, and 2/26 (7.7%) werestill not fully continent.These outcomes of differentmodels ofrehabilitation for urinary incontinence (PFMT + BFB versusPFMT + SSS) appear to be more favourable for Subgroup IB(Figure 2).

Analysis for the entireGroup I shows a significant correla-tion between therapeutic outcome and the physiotherapeuticmethod used (Chi2, 𝑃 = 0.00007). There were considerablymore incontinent patients in Subgroup IA (61%) than inSubgroup IB (8%) on completion of the therapy. The studydid not demonstrate statistically significant differences withrespect to incontinence between Subgroup IA versus IB(𝑃 = 0.08). A comparison of continence outcomes revealeda statistically significant difference between Subgroups IAversus IB (𝑃 = 0.007). The highest percentage of continent


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INCC

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Figure 2: Comparison of outcomes of incontinence therapy (Cversus INC) for Subgroup IA (PFMT + BFB) versus Subgroup IB(PFMT + SSS).

patients following physiotherapywas in Subgroup IB, at 24/26(92%).

We also studied the effect of time between prostatectomysurgery and commencement of physiotherapy on conti-nence outcomes. The patients were accordingly divided intotwo subgroups. Subgroup A comprised patients who beganrehabilitation within 3 months of surgery and Subgroup Bincluded those who reported for rehabilitation three monthsormore after surgery.Thepatientswere additionally classifiedas continent (C) and incontinent (INC).The analysis showedthat the best continence outcomes were obtained in patientswho entered rehabilitation within three months of surgery.Differences in the odds ratio for continence between Sub-group A (<3 months) versus B (>3 months) were in favor ofthose who entered rehabilitation earlier. The odds ratio forthe recovery of continence in Subgroup A amounted to 4.88while in the group B 0.29. These results emphasize that thechances for regaining full continence decrease considerablywith increasing time between prostatectomy surgery andentering rehabilitation.

Analysis of data for the entire study population (𝑛 =81) revealed differences in continence/incontinence betweenmales from Group I versus Group II (33/49 versus 4/32; 89%versus 11%). Superior continence outcomes were obtained inGroup I versus Group II (33 versus 4) and the differencewas statistically significant (𝑃 = 0.0001). The odds ratio forregaining continence was greater in rehabilitatedGroup I andsmaller in the group II without the rehabilitation. The oddsratio for the recovery of continence in Group I amounted to2.06 while in the Group II 0.15.

The results are presented in Figures 1, 2, and 3. 1-hourand 24-hour pad testing did not reveal significant differencesin the amount of urine loss between Group I (rehabilitated)versus Group II (not rehabilitated) before rehabilitationbegan.The consumption of pads decreased significantly (𝑃 <0.001) on completion of the therapy compared to baseline.

0

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Figure 3: Therapy outcomes (C versus INC) in Group I versusGroup II.

On completion of the therapy, 9/23 patients in SubgroupIA were continent compared to 24/26 in Subgroup IB. BFBproduced statistically significant changes (𝑃 = 0.03) only inresponse time as measured by sEMG. Incontinence followingtherapy was still present in 14/23 patients in Subgroup IA and2/26 patients in Subgroup IB. Superior continence outcomeswere noted in patients who had entered rehabilitation within3 months of prostatectomy surgery compared to those whohad taken longer to begin rehabilitation (Subgroup A versusSubgroup B; OR 4.88 versus 0.29). Analysis of the entirestudy population (𝑛 = 91) revealed superior continenceoutcomes in Group I versus Group II (33/4), representingbetter odds for regaining continence in rehabilitated patientsversus nonrehabilitated controls (OR 2.06 versus 0.15).

4. Discussion

Themanagement algorithm for urinary incontinence in menfollowing radical prostatectomy is not fully specified withregard to both the choice of physiotherapy methods, timing,and duration of therapy and exercise intensity [13–20]. Therisk of incontinence may be influenced not only by the surgi-cal method and operative technique but also by other atten-dant factors [18, 21], such as age, prostate volume, tumor stage,history of TURP (transurethral resection of the prostate), andvolume leaked following catheter removal [22–24]. Porru etal. described amuch higher rate of resolution of incontinenceand dribbling symptoms in a rehabilitated group versus acontrol group [25]. The authors recommend physiotherapyexercises on account of their efficacy and ease of execution[25]. Guidelines regarding the timing of physiotherapy varybetween authors. The timing of therapy is important forcontinence outcomes [17, 23]. In our study, patients reportedfor physiotherapy at various times following prostatectomysurgery. They were admitted for rehabilitation on the basisof a referral note for physiotherapy from their urologists.The data show that Subgroup A (<3 months between surgery


and rehabilitation) had greater odds for regaining continencethan Subgroup B (>3 months). Physiotherapy for continencewas more beneficial in patients who started treatment up to3 months following prostatectomy versus those who enteredrehabilitation after a longer interval (Subgroup A versusSubgroup B, OR 4.88 versus 0.29). The chances for completerecovery of continence decreased considerably with increas-ing interval between surgery and beginning of rehabilitation.A review of the literature showed that both the duration ofsupervised therapy and session frequency are not uniformacross published papers [7, 14, 16, 22, 26, 27]. In the presentstudy, as in van Kampen et al.’s, the therapy continueduntil micturition control had been regained and also didnot exceed 12 months [22]. All patients from the groupundergoing rehabilitation had one-on-one sessions with thesame physiotherapist. Similar to other studies, two sessionsa week were held and each lasted on average 30 minutes[3, 23]. Patients were instructed to repeat a set of exercisesat home 3 times a day in sessions not exceeding 20min.Overgard et al. demonstrated that superior increments inmuscle diameter and strength could be obtained with twice-daily versus once-daily exercise sessions [7]. The 1-hour and24-hour pad tests were used to compare urine loss betweenGroup I and II at baseline (before rehabilitation commenced),but did not reveal statistically significant differences (𝑃 =0.329 for 1-hour pad test; 𝑃 = 0.105 for 24-hour pad test),which means that the two groups were comparable withrespect to the amount of urine leaked. van Kampen et al.observed that low urine loss immediately following catheterremoval may be prognostic for rapid recovery of continencefollowing prostatectomy [22]. Published studies have used the1-hour pad test to assess the amount of urine leaked. Thistool has been recommended for that purpose by ICS [28, 29].Borgermann et al. point out that a variety of criteria areused to classify a postprostatectomy patient as “dry” [30]. Forsome researchers, a patient is continent when he does not useany protection while for others a continent patient does notuse one and/or more pads [19, 30]. The present study reliedon micturition diaries to obtain data on pad consumptionin Group I (𝑛 = 49). Pad consumption decreased aftertherapy in a statistically significant manner compared tobaseline (𝑃 < 0.001). Micturition diaries are another effectiveand noninvasive tool for assessing incontinence. Researchersvary in their opinions about the optimal number of records.Some recommend keeping a diary for 7 days [31], whileothers make do with 4-day records [32]. In the presentstudy, patients kept micturition diaries for 4 days. Methodsof treatment of iatrogenic urinary incontinence followingprostatectomy in men include biofeedback [16, 17]. However,this is not a method in itself. It is only a tool helpingpatients achieve exercise goals. The sound and vision makeit easier to monitor exercise tasks. Our study used sEMGto measure and monitor pelvic floor muscle contractions.Various outcomes have been reported with this kind oftherapy. Ribeiro et al. used biofeedback combinedwith sEMGmonitoring of muscle activity to train pelvic floor muscles.The biofeedback group registered much better continenceoutcomes compared to the control group [19]. Some reportshave stated no effect of BF on the efficacy of continence

recovery [13, 33]. In our study, PFM training combinedwith biofeedback was also used in Subgroup I. Performanceof exercises was monitored by the registration of actionpotentials from muscles during contraction and relaxation.Of all indices monitored, a statistically significant difference(𝑃 = 0.03) was only observed with regard to response time atbaseline versus on completion of therapy, whichmay indicateimproved timing in neuromuscular coordination. However,the additional incorporation of biofeedback in Subgroup Idid not increase the efficacy of continence recovery, similarto the findings of other studies [13, 33]. Some authors believethat patients with incontinence following prostatectomy mayregain continence spontaneously within one or even twoyears following the surgery [22, 30, 34]. In order to ensurean objective assessment of our therapy, we followed up bothrehabilitated and nonrehabilitated patients. More patientsregained continence in the physiotherapy group, with 33/49(67.3%) continent patients in Group I, compared to 16/49(32.7%) incontinent patients. In Group II (nonrehabilitatedcontrol group), continence was confirmed in 4/32 (12.5%)patients and 28/32 (87.5%) remained incontinent. In ouropinion, these comparative data encourage the use of physio-therapy inmenwith this dysfunction. Studies of incontinencepresent results of single-modality therapies [14, 17, 20, 35, 36].The present study compared continence outcomes in patientstreated with a combination of two methods. Patients in Sub-group I entered a biofeedback-enhanced exercise program forpelvic floor muscles based on spinal segmental stabilizationtraining, while those in Subgroup II only practiced pelvicfloormuscle exercises based on segmental spinal stabilizationtraining. The addition of biofeedback in Subgroup I did notbring about a dramatic increase in the efficacy of continencerecovery.

Pelvic floor muscles are morphologically classified asskeletalmuscles and so they adapt to exertion in the samewayas do other muscles from this group. Regular training leadsto an increase in muscle bulk, which can also be observedin pelvic floor muscles. Endurance and strength training forincontinent patients aims to change muscle morphology byincreasing their diameter, improve neurological indices byincreasing the numbers of active motor neurons and thenumber of excitatory stimuli, and improve muscle tone [11,37, 38]. Factors that slow down muscle responses to exertioninclude age, which is also associated with slower responsetimes. Older (>70) men were found to have grossly limitedability for migration of the urethra against the symphysispubis and had blurred anatomical borders of the urethralsphincter system [39]. Increased diameter and endurance ofpelvic floormuscles are achieved using the principles of train-ing designed for other skeletal muscles as pelvic floormusclesare made up of striated tissue. It is not completely under-stood how these training principles translate into changes inthe continence muscles. Good neuromuscular coordinationappears to be of immense importance for normal pelvicfloor muscle function. The muscles of the pelvic floor havedifferent points of origin and attachment in that region.Some attach directly to bones and others to fasciae andligaments. In describing the functions of pelvic floormuscles,Shafik points out that the external anal sphincter (EAS),


external urethral sphincter (EUS), and the bulbospongiosusmuscle (BC) have their origins on the puborectalis muscle(PR) and act as a mutually dependent muscle complex. Hisstudy demonstrated that pelvic floor muscles behave likeone muscle, which does not preclude the possibility of themworking independently from one another [40]. A numberof strategies for activating pelvic floor muscles are available.These strategies are based on isolated muscle tensing, func-tional training andmotor control, the use of muscle synergiesinvolving the transversus abdominis muscle, and the use ofappropriate breathing patterns [41]. Some researchers believethat the pelvic floor muscles are part of a structural complexthat forms a lumbopelvic cylinder comprised of the pelvicfloor, respiratory diaphragm, transversus abdominis muscle,and lower spine, including themultifidusmuscle [42].Mutualcoordinated relationships between these components resultin increased intraabdominal pressure, which has a stabilizingrole. A rise in intraabdominal pressure precedes an increasein intraurethral pressure [43]. A relationship between PFMactivity and intraabdominal pressure contributing to urethralelevation was demonstrated by Junginger et al. [44]. Toprevent urine leakage, the actively contracting pelvic floormuscles increase urethral closing pressures and are accord-ingly viewed not only as stabilizers but also as promoters ofabstinence. Other researchers emphasize the importance ofthe transversus abdominis (TrA) as a significant structuretaken advantage of in exercises for incontinent patients.The function of the transversus abdominis in generatingpressures transmitted onto the pelvic floor muscles has beenextensively studied. The hypothesis that the roles dependon the site of origin/attachment of a muscle is yet to befully confirmed [45]. Junginger et al. demonstrated thatelevation of the bladder neck is consistently seen whenpelvic floor muscles are tensed in combination with mildtensing of TrA. Inhibition of urethral elevation was seenwhen abdominalmuscles were slightly tensed in combinationwith a slight Valsalva maneuver and raising of the head[44]. The authors suggested that their findings should beincorporated into plans for the rehabilitation of patients withurinary incontinence.They indicated that PFM and TrAwerejointly activated only during submaximal tensing, while 100%tensing caused an excessive rise in intraabdominal pressure asa result of the activation of all abdominalmuscles, which low-ered the bladder neck. Thus, the authors concluded that onlysubmaximal PF tensing should be achieved therapeutically[44]. Sapsford suggested that a contraction of the transversusabdominis may facilitate tensing the pubococcygeal part ofthe levator ani [46].

Other researchers suggest, on the basis of their findings,that tensing abdominal muscles facilitates the tensing ofPF muscles. Jones believes that viewing the role of pelvicfloor muscles in a broader perspective paves the way forother rehabilitation modalities that can now be used for thispurpose [42]. She notes that physiotherapy methods used forthe selection of exercises for incontinent patients and thoseemployed in the treatment of back pain and spinal instabilityhave a lot in common as both take advantage of connectionsbetween muscle groups in the lumbar region, abdominalmuscles, and pelvic floor muscles.

The role of this muscle complex is to produce and controltensions in response to changes in intraabdominal pressure.Richardsoan et al. point out that good control of pelvic floormuscle tension is an important element of the restorationof abdominal stabilization in incontinent patients [47]. Intheir work with patients, physiotherapists do not “train” onlyone muscle. Approaching the dysfunction as a local problemmanifesting only at one site in the body is not sufficient inview of the current knowledge of physiology, biomechanics,and neurology. One has to agree with Dr. Lee, who notesthat “understanding musculoskeletal disorders requires anawareness of how loads are transferred by the body andhow a disturbance in one part may affect the functioningof the entire system” [48]. Many authors have tried, firsttheoretically and subsequently in practice, to explain themechanisms underlying mutual effects that muscular andfascial structures exert on one another. Researchers whohave worked to unravel the integrity of these structuresinclude F. Meziera and K. Tittel. They have presented cer-tain connections related to muscle chains whose mutualrelations stemmed from functional links [49]. A similarview was presented by Myers in “Anatomy Trains,” wherehe pointed to musculofascial connections as the bearers ofmutual links. Kassolik and Andrzejewski similarly soughtlinks in musculofascial connections in their tensegrationmassage theory [50]. All these authors based their pro-posals on the assumptions of tensegration formulated byBuckminster Fuller. With this approach, the human body,particularly the musculoskeletal system, is viewed as a wholesubject to continuous shifts between stability and mobility,which is associated with constantly shifting tensions andthe emergence of compressions in the human body bothin movement and at rest. These aspects are explained byD. Ingber [51]. Approaching the musculoskeletal system asa spatial musculonervoskeletal structure is conducive tofinding muscle connections that can be used in workingwith patients and whose role can be understood solely byreference to their structural and functional relations. Similarassumptions were presented by D. Lee based on earlierwork by Vleeming. D. Lee introduced an easily understooddivision of muscle trains into an external and internal group.Connections between muscle trains as presented by her areused in restoring stability of the lumbar spine and pelvicgirdle, but have also been employed in the treatment ofurinary incontinence [48]. The conception of stabilizationand appropriate choice of exercises has been presented byother authors, including Dr. Richardsoan et al. [47]. Urinaryincontinence is associated, among others, with functionalweakening of the pelvic floor muscles, which are regarded asdeep (central) stabilization structures. Jones emphasizes that,when the identification of pelvic floor muscles is disturbed,the use of other muscles forming the central stabilizationcylinder results in tensions being automatically transferredonto the muscles of this region [42]. The pelvic and sacralbone are the sites of attachments of approximately 35muscles;therefore, their mutual relations play a role in the movementand stabilization of this region of the body as well as othersegments. Our approach to working with incontinent malesfollowing prostatectomy is based on principles used in central


stabilization training, especiallywith regard to trainingmotorfunctions, proposed for that purpose by Richardsoan et al.Their training principle involves a system of three successivestages of rehabilitation offering progressively increasing loadsand always taking into account local segmental control. Inline with Richardson’s recommendation, tensions used dur-ing training sessions with patients did not exceed 30% of theMVC. Movements were performed at a slow pace in order toactivate tonic muscles [42, 48, 52]. The duration of sustainedtensing was 10 s with 5–10 repetitions, in accordance withLibenson’s instructions for this type of training [52]. Therehabilitation also involved “functional respiratory patterns”as proposed by Sapsford for strengthening pelvic floor mus-cles in incontinent women [46]. The author refers to mutualrelations in the inspiratory and expiratory phase betweenthe abdominal muscles, respiratory diaphragm, and pelvicfloor muscles. Exercises during the respiratory phase werealso used during sessions with patients by Ribeiro et al. [19].Published strategies of management of urinary incontinencehave been changing, from local approaches to the problem[53–57] towards concepts linking pelvic floor muscles withother muscle groups forming a functional whole [46–48].State-of-the-art knowledge affords a better understanding ofrelationships within the musculofascioligamentous system inthe space of the pelvic floor and the cylinder formed by therespiratory diaphragm, abdominal muscles, and lower back.Imbalance between these structures produces functionalchanges. The ability to grasp mutual relationships in thelocomotor system enables for the therapeutic use of theinfluence of particular elements on other components that areoften not directly related.

5. Conclusion

The findings of the present study show that a physiotherapyprogram can improve or fully restore continence. Data for theentire Group I suggest that early institution of physiotherapyafter a prostatectomy procedure contributed to regainingcontinence. Continence outcomes were better in the rehabili-tated group compared to nonrehabilitated controls.The studytools (pad testing, micturition diaries, and sEMG) proveduseful for our analyses and presentation of the results of thestudy.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

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